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Wednesday, June 06, 2012

colic, ahead of schedule

Let me start the story by telling you that yes, this was my arm at around 3:00am this morning.

But maybe let me back up for a moment first.

I was overnight call last night. At our hospital, because we don't have OB or a significant trauma population, we take home call, meaning once the scheduled cases and add-ons are done for the night we can leave the hospital and come back in if there's an emergency requiring anesthesia. I left the building around midnight and got in my car.

On my drive home (I only live about 10-12 minutes from the hospital, so we're not talking a real long drive here) I started to get some epigastric pain. Up high, under the xyphoid, but intermittent, diffuse and colicky. It did not feel like Braxton Hicks contractions, that much I could ascertain by just poking at my stomach with a finger--one of the many benefits of having had two other kids is that I know what uterine contractions feel like, which is where the consistency of your uterus as palpated from the outside basically goes from feeeling like a Nerf soccerball to a regulation bowling ball. This was not that. It also felt different from the reflux that I've been having on and off for the past few weeks. I wouldn't even really classify the reflux I've been experiencing as pain, more of an annoyance--kind of a fullness and urpiness with some occasional ascending pressure--but I had a bottle of antacids in my work bag and when I stopped at a red light I went ahead and took two of those. Before I got in my house I went ahead and took two more, because the first two didn't seem to have helped at all. The second two didn't either.

Everyone in the house was sleeping when I got in, so I tried to hobble upstairs quietly to get changed. The pain was much worse. Epigastric, diffuse, severe, worse with movement. So I thought maybe I should just like down on the carpet until it got better. It didn't get better. Somehow I wormed out of my work clothes (I was still lying down, so "worming" is actually a very accurate description of my efforts), put on a tank top and a pair of boxers, and kind of shambled into bed, thinking that the soft surface would help, and hell, this had to let up soon, right? I'd had nothing special for dinner (you know, a sandwich, some iced tea, a handful of chips--eaten hastily between cases but not much more so than usual) and possibly one of those things were disagreeing with me. I particularly cast a jaundiced eye on the sandwich, which, while it was freshly prepared that morning in front of me in the supermarket and had been in the fridge the whole time until I ate it, I suspected was the most likely culprit. I know everyone tells The Pregnants to stay away from cold cuts because of the risk of listeriosis, but I've never really listened to that--how can you work in a hospital and not eat sandwiches? I mean, I won't eat cold cuts that have been sitting our for hours or anything, but otherwise, late nights, I would have nothing. Anyway, I don't get listeriosis under normal conditions, right? Whatever. The damn sandwich, am I right folks?

The pain was beginning to get much, much worse. I couldn't lie still, for one--each wave of pain had me writhing around, and there was no comfortable position to be had. I could still feel Thing 3 squirming around inside, which was reassuring, but also excruciating, because every well-aimed jab at the fundus or foot to the ribs made the pain, like, ten times worse, as was any effort for me to engage my abdominal muscles at all to sit up or move. I've had two kids and this pain was far worse than anything that I experienced during either of my two labors (and granted, I had epidurals for both, but it's not like they popped them into my back the second I walked in the door--I know what unmedicated active labor feels like, even augmented on Pitocin.) The closest thing, honestly, that this felt like was when I went to the ER with a raging peritonitis when I had that perforated appendix in med school. And that was pretty bad, not to mention dangerous.

So I started considering my options. Like most medical people I tend to minimize when it comes to triaging my own ailments (part of it is that we see so much worse stuff in our patients day-to-day that it seems indulgent to catastrophize your own--the other part of it is that we know being a patient in the hospital is THE WORST) but when I was thinking through the differential and the worst case scenario for waiting versus heading into the ER, it did seem like there might be a time-sensitive element to going in sooner rather than later. Basically my two main concerns were pre-ecclampsia/HELLP syndrome or some grade of placental abruption. Would I feel worse going into the hospital for a false alarm or worse waiting at home for it to blow over and having something potentially catastrophic happen with the baby? It was a no-brainer. I knew I had to go in.

(It also should be said that anytime you get a pregnant patient on the Anesthesia oral board exam something terrible happens to them and everyone dies, so yeah, maybe I was thinking about that a little bit too.)

I crawled over to Joe in MEGABED (I couldn't really stand up that well anymore) and woke him up. "I think I should go into the hospital," I said, and explained what was going on. I really didn't want to wake the kids up (it was past 1:00am at this point) but I didn't think I could drive myself in anymore and short of calling a cab, I wasn't really sure what else to do. Joe immediately jumped into action--getting things ready, getting the kids dressed, gathering the appropriate materials. I, meanwhile, crawled over to the bathroom on all fours and started making friends with the toilet. I wasn't throwing up or anything, but I felt kind of sicky and remember, the retrospectively ill-advised white berber carpeting.

By the time the kids were dressed Joe was looking very concerned. "Do you want me to call an ambulance?"

"Nah," I gritted out, "It won't...be any...faster...let's just...drive in." And then I writhed around some more on the floor and tried to breathe a little bit between the painful gut twisting.

Joe called the ambulance.

We explained to the 911 operator that we really didn't think it was premature labor (see: uterine contractions, lack thereof) but anytime you are 34+ weeks pregnant with excruciating abdominal pain, obviously that's what people are going to think. Joe helped me down the stairs (I really couldn't walk at all by this point), the ambulance pulled up, and after a very quick history, we scooped and ran. We tried to shoo the kids away back into the bedroom so they wouldn't be traumatized, and I kept reassuring them that MOM'S FINE, JUST A LITTLE SICK, EVERYTHING'S GOOD (giving them increasingly manic smile rictuses/thumbs ups) but they seemed more fascinated than anything else, especially when the ambulance and the fire truck pulled up. (I guess they always call the fire truck in tandem, even without overt fire. Not really sure why.)

The pain started getting better once we got to the hospital, and after some monitoring and labs, I felt almost normal again. (Joe confirmed also that I was looking 100% less like death.) My OB wanted to get an abdominal ultrasound to rule out gallbladder pathology (with pre-ecclampsia and abruption mostly off the table I think that's an abundantly reasonable diagnosis) but that failed to qualify as an emergency scan so I stuck around L&D urgent care for another couple of hours until the ultrasound techs clocked in at 8:00am.

The long and the short of is was...nothing. They didn't find anything. Labs were normal. Urine was normal. BP was high in the ambulance (though not too surprising, see: pain, ambulance, very bumpy hospital transfer) but came back down to almost normal over the next few hours. Abdominal ultrasound of kidney, pancreas, liver and biliary system was unremarkable--if pushed, the tech thought maybe the gallbladder looked a little contracted, maybe, but that seemed more to me like a desire to give us some explanatory finding rather than anything definitive or concrete. No visible stones or signs of inflammation. Best guess--maybe I had a small stone that passed, causing pain and explaining the ultimate resolution. Possibly. But who can say, really?

They made me eat some breakfast to make sure that wasn't going to set me off again, and after recording one more strip of Thing 3 (reactive, perky, hates being monitored and kept swimming away from the doppler) they removed my IV and sent me on my way. Luckily, though I was actually on call last night, I didn't get called back in. Also luckily, because I was on call last night, I'm post-call off today and so I didn't have to miss any work. And I know 75% of you right now are groaning, like, who cares if you missed work, you were in the ER, but many of you who work in medicine or other similar jobs understand--you don't like to call in sick, ever, even if, you know, you kind of are. I'm feeling pretty much normal now, so if everything stays cool, I'm all set to get back to the hospital tomorrow. My own hospital, I mean, as a doctor. Where I can put the IVs wherever I want. (What is it with the Emergency Department and anticubital IVs? Seriously guys, save that one for the Hail Mary--if there are other choices on non-bendy parts of the arm, those are far more functional. That said...a billion thank yous for taking such good care of me--I don't really care, stick me wherever you want, I love you.)

In the end, it's sort of an ultimately unsatisfying patient encounter I guess, because there was no answer to what caused the pain, which I maintain was among the worst episodes of pain I've ever felt in my life. But we turned over most of the big, potentially disastrous stones and found nothing--I'm fine with not ever knowing honestly, so long as it's not dangerous and (fingers crossed), doesn't happen again. Anyway, at least the kids got a free adventure out of it--they'll be talking about it for days. Cal was so excited that he grabbed his journal before Joe stuffed him into the car and had this whole entry written by the time he got in to memorialize the happy incident. (The "salty" smell he's talking about is the ubiquitous odor of the hospital antiseptic. I mean, I hope that's what he's talking about. Otherwise, I don't want to know. Also, ew.)

In my first pregnancy I was in the hospital with stabbing chest pain. (It was at Emory where they have no L&D and the Doctors were FREAKED OUT because they never see pregnant women.) Was there for hours and hours and tests and tests and finally they said, "Um, we THINK you have pericarditis maybe?" They wouldn't even give me a prescription for an NSAID, so terrified were they of my pregnant belly. Had to see my OB the next day. Was super lame. I feel you. Yuck.

so relieved it passed. my 1st thought when reading your description was gall stone...happened to me during my 2nd pregnancy and was WAY worse than my 1st, non-medicated birth. i wasn't sure what it was (not being a doctor type), but was fairly sure it wasn't a heart attack. lasted for a few hours -- ending right as we got to the hospital. then no more attacks till 9 years later when i really REALLY got sick and ended up in the hospital when it turned gangrenous. good times.

Cal is more literate than a lot of high school grads I know. What 6 (7?) year old has handwriting that good? *I* don't even have handwriting that good! (Future surgeon perhaps?)

I am so glad everything's ok with you and Thing 3! I went through something similar at 30 weeks (bad epigastric pain that didn't get better quickly -- I also thought I must have had food poisoning), turned out to be crazy-ass serious looking 2 minute spaced contractions. Resolved with fluids. But soooooo didn't feel like what labor ended up feeling like.

Hey, just make sure you keep getting your BP checked occasionally at work. Really don't want to miss a HELLP situation - although I know your LFTs were okay this time around. But I agree, most likely a terrible gallstone that passed on.

Do you like conjecture from a non-medical person? That kind of pain sounds like a kidney stone.

My mom (who did not have a c-section when she had almost 6 and almost 7 pound twins with 1 breach) had a kidney stone and said it worse pain than giving birth. I've also known a couple of pregnant women that have had them.

Wow...glad to know everything turned out OK. I'm sure it scared a few people half to death in the process, however. Hoping for smooth sailing from here on in until Thing 3 arrives safe and sound at term! I thought gallstone, too, from the description. Apparently gallbladder issues are not uncommon in pregnancy. Whatever it was, here's to no repeats!

KWeaver - actually the ambulance does carry all their own emergency equipment (what if the fire engine couldn't come with them because they were at an acutal fire?). A lot of ambulances are pretty big, and they are really good at utilizing their space. The real reason the engine comes is two-fold - one is that they provide more manpower in case Michelle HADN'T been able to get herself down the stairs, and the other is that if they came from separate locations (e.g. the engine was at the firehouse but the ambulance came from the hospital) the firefighters could start providing care - they have at least minimal first aid training and may even be certified as EMTs or Paramedics.

Oh my goodness! I'm glad you're OK, but PLEASE take it easy, woman! I empathize with the med. school provider not wanting to call out sick bit, but listen to other people that are telling you to rest. I always feel like I need permission from someone else...like, when I am CLEARLY febrile, delirious, and coughing up sputum, I STILL go to clinic, because having the attending send me home is somehow less worse than just saying I can't come in to begin with. Don't be me! You are growing a human right now!

I would like to read the rest of Cal's journal. Looks like the previous page has something about "VECTOR TRICKS". Seriously, if that's referring to his graphing calculator, call that kid Doogie and send him to high school already!

Last night was apparently the night for preggos to have epigastric pain! I'm now 28 weeks and had THE WORST heartburn/indigestion EVER last night. I've had gallbladder attacks in the past and this was close. I wonder if Venus in transit was messing with us??? :)

You gotta be careful with your titles! The neonatologist in me was so worried THE BABY came "ahead of schedule." I'm glad you're both doing well, although I totally empathize with the dissatisfaction of not knowing a good explanation of what exactly happened.

How has everyone else glossed over "Also, Mom is never in a push-up position..."? Hilarious! Kids really do say the darndest things.

Maybe you were constipated? When was your last bowel movement? I hope the baby doesn't come too early, but at least you are in the third trimester and past 32 wks. When I was pregnant with my second, I was literally counting the days and weeks before I could breathe a sigh or relief!

Woah. I ended up in the ER on Memorial Day s/p a liver biopsy because I had pretty much the EXACT same symptoms you had and was worried about everything from internal bleeding to a MI. They ran blood on me and a CT scan, but also turned up nothing. But that pain was so excrutiating I really thought I was dying for a while. Hopefully you weren't treated like just another crazy lady like I was.

Michelle, I was so scared for you and the baby reading this. I'm very happy that all seems much better now. By the time I got to Cal's journal entry you had already told us that you were better and back home which allowed me to double over in laughter at his words. He is soooo smart and obviously he has inherited your sense of humor.

Hi,Dr. Michelle. You really have a gift of writing. I've read some of your blogs. I really like how you tell the story. It seems like I'm also part of it. hehe! Oh, good news! You are okay. Keep safe always. :)

It's not the ER's fault with the AC IVs...we get yelled at by everyone else (radiology, the floors, the OR RNs, the list goes on and on) if we pop an IV anywhere BUT the AC. But I agree with you that there are perfectly appropriate places elsewhere!

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